The Transitional Care Social Worker is responsible for the navigation and advocacy of identified members stratified relevant to care transitions. These members require coordinated transitional care and integration into multiple health and social systems. This may include providing the member with information and assistance to access a wide spectrum of services directed at social, medical/behavioral and lifestyle interventions to promote health and wellness and support individualized goal attainment through care planning and self- management to prevent readmissions, demonstrate continuity of care, assist with discharge planning and SDOH needs for members at high risk for readmssion, members who have exhausted benefits, redirection of members who are utilizing out of network providers, facilitiating access to care for members who were seeing a provider who has termed with THP, transitioning care onto or off of THP to ensure continuity and providing support and directioin to members with high cost or complex care needs.

Required

• Social Work or related undergraduate degree with active and unrestricted license in good standing as a social worker in Ohio or West Virginia upon hire. All licensed staff are expected to hold active licenses in both Ohio and West Virginia by the end of their 90 day probationary period with demonstrated compliance with licensure and Board of Social Workers continuing education policy throughout hire.
• Relevant experience in a hospital, skilled nursing facility, outpatient unit or related setting.
• Excellent oral, written, telephonic and interpersonal skills to balance independent and team work environments.
• Demonstrated knowledge of Microsoft Office programs.
• Flexibility, ability to multi-task and work in a fast-paced environment and adapt to changing processes.
• Proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
  
  

Desired

• In-depth knowledge and skills related to care resources, community resources, discharge planning and health care financial environments. Remains current through conferences, workshops and professional networking.
• Superior work ethic and commitment to excellence and accountability.
• Ability to demonstrate independent and sound judgment in decision making, utilizes all relevant information to proactively identify and resolve issues.
• Masters of Social Work desired but not required.
• Case Management Certification (CCM) or Certified Advanced Social Work Case Manager desired but not required.
  
  

Responsibilities

• Engages telephonically with members identified as high risk for hospital readmissions or transitional care need through direct communication with hospital social workers and discharge planners, network practitioners, other transitional care staff, case managers, and The Health Plan members or supportive others.
• Assists The Health Plan members identified with any transition of care need and/or their supportive others, The Health Plan staff, or practitioners in making community resource referrals. Also provides appropriate follow-up regarding the outcome of a referral.
• Performs research to identify appropriate community resources and maintains information of available resources to meet various member needs.
• Completes accurate and timely documentation of contacts, needs assessments, interventions and outcomes in The Health Plan's EMR platform.
• Collaborates with Health Plan staff in providing practitioner and facility education regarding available support services to assist members with transitional care needs.
• Works with The Health Plan staff to develop and implement programming for social intervention consistent with identified needs of specific member populations i.e. Medicare and Medicaid.
• Maintains a level of competency to deal with current SDOH trends, exhaustion of benefits by line of business, transition on or off THP insurance to ensure continuity of care.
• Strives to improve quality in all areas of responsibility and cooperate with all departments to improve quality throughout The Health Plan.
• Serves as assigned on departmental or company committees.
• Promotes communication, both internally and externally, to enhance effectiveness of transitional care services.
• Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to management.
• Prioritizes assignments appropriately and maintains flexibility as new priorities arise.
• Participates in Transitional Care and Post Discharge Outreach.
• Social Workers are responsible for reporting any changes in licensure (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary actioin by a licensing board) to their direct supervisor through their term of employment.